HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 LACY STREET 4/17/2025 � of North Andover
Commonwealth of Massachusetts
City/Town of ). c vv,� )z, MAMAY5 2025
w System Pumping Record
Form 4 a.. Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information�.�
Important:When
filling out forms 1. System Location:
on the computer, G, -
use only the tab �J_ 41 LC K,'S_( "
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
VQ _2. System Owner:Name
SAM E
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 _.
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F-1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes X No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Cmc)0 All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. S Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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